Please answer all questions to the best of your ability. Patient name: Date: SS#: Age: Address: Date of Birth: City/State/Zip Code: Sex: MALE FEMALE
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1 Please answer all questions to the best of your ability. Patient name: Date: SS#:_Age: Address: Date of Birth: City/State/Zip Code: Sex: MALEFEMALE Phone (home): (work):(cell): Marital Status: address:how did you hear about us? Primary Care Physician: Phone: Address of Primary Care Physician: Other Physicians involved in your care: Employment status: Full-time_ Part-time Not Employed_ Employer: Occupation: (If self-employed, please state the name of the Company) Employer Address: Emergency Contact Name: Realationship: Phone (home): (work): (cell): Patient Insurance Information: Company Subscriber Name: Subscriber Date of Birth: Employer: Policy #: Group #:Phone #: Secondary Insurance Information: Company: Subscriber Name: Subscriber Date of Birth: Employer: Policy #: 1/24/2014 1
2 Group#:_Phone#: By signing below, I authorize Methodist Physicians Clinic to share my medical information relating to my use or need for weight loss surgery with my health insurance plan. This information can include spoken or written facts about my medical condition including copies of my records from Methodist Physicians Clinic healthcare providers, Methodist Hospital, Methodist Jennie Edmundson Hospital or Methodist Women s Hospital. Methodist Physicians Clinic will use and she this information with my health insurance plan to see if I has coverage and/or benefits for weight loss surgery. This authorization will last for one year after the date I sign this form. If I change mind before that time, I can contact the Methodist Physicians Clinic Director of Health Information Management in writing and tell them that I do not want them to share any more information with my health insurance plan. I understand this will not change any action taken before I revoked this authorization. I know that I have a right to see or copy the information Methodist Physicians Clinic has given to my health insurance plan. I understand that I may refuse to sign this form. My decision to sign this form or not will not affect the way my healthcare providers treat me. If I refuse to sign this form I understand that this means I will no longer receive assistance from Methodist Physicians Clinic to determine my health insurance benefits for weight loss surgery. I understand that Methodist Physicians Clinic does not promise to find ways to pay for my weight loss surgery and I know that I may have to pay the costs of my care. Patient Signature:_Date: (If you have already signed an insurance verification form, you do not need to sign this again) _ How long have you been overweight? (Please circle the most appropriate response) All my life (childhood) Adolescent (high school/teenager) Adult After Pregnancy After a Specific Event or Injury Other: Have you had prior weight loss surgery? Yes No If yes, pleas indicate type of surgery: Date: Where was surgery was performed: By whom: What is the most you have ever weighed? Weight: Date: What diets and medications have you tried in the past to lose weight? (Please include dates and amount of weight loss) _ 1/24/2014 2
3 Have you ever been treated for an eating disorder? Anorexia Yes No Bullemia Yes No Binge Eating Yes No Other: Do you have any food allergies or food intolerances? (Please list these foods) Do you skip meals? Yes NoWhich meals? How often?_ Do you do your own grocery shopping? Yes No Who does the cooking at your house? Do you eat out? Yes No How often?where? List any diet restrictions you have or any special diet guidelines you follow: Please list all of your past surgeries, include all out-patient surgeries. Type of Surgical Procedure Date Place Surgeon Have you ever been hospitalized for any other medical illness? Reason for Hospitalization Date Place Physician 1/24/2014 3
4 Have you ever been admitted to a mental health/psychiatric hospital or received treatment for a psychological or psychiatric Condition: Reason for Hospitalization/Treatment Date Place Physician Current Medications: Please include any herbal supplements as well. Type of Medication Dosage of day taken Prescribing Physician Do you have any allergies to medications, food, latex or others? Yes No Please list allergies below _ Type of Reaction 1/24/2014 4
5 Do you have or have you ever been diagnosed with: (please circle Yes or No and provide onset information) a. Hypertension Yes No Onset: Congestive Heart Failure Yes No Onset: Chest Pain Yes No Onset: Other Heart Conditions: Yes No Onset: b. Diabetes Yes No Onset: Other Endocrine Disorders (Thyroid, Adrenal) Yes No Onset: c. Sleep Apnea Yes No Onset: Blood clots to your lungs (Pulmonary Emboli) Yes No Onset: Shortness of Breath Yes No Onset: Other Lung Conditions (Asthma, Bronchitis) Yes No Onset: d. Arthritis/Orthopedic Conditions of Your: Neck: Yes No Onset: Upper Spine/Back Yes No Onset: Lower Spine/Back Yes No Onset: Hips Yes No Onset: Knees Yes No Onset: Shoulders Yes No Onset: Ankles/Feet Yes No Onset: e. Fibromyalgia Yes No Onset: f. Lower Extremity Problems: Varicose Veins Yes No Onset: Lymphedema/Ankle Swelling Yes No Onset: Venous Skin Ulcerations/Breakdown or 1/24/2014 5
6 Discolorations to skin Yes No Onset: Other lower Extremity Conditions Yes No Onset: g. Gastrointestinal Disease or Disorders: Heartburn/Reflux Yes No Onset: Difficulty Swallowing Yes No Onset: Diarrhea Yes No Onset: Constipation Yes No Onset: Ulcers Yes No Onset: Colitis Yes No Onset: Diverticulitis Yes No Onset: Irritable Bowel Syndrome or IBS Yes No Onset: Fecal Incontinence Yes No Onset: Other Gastrointestinal Conditions Yes No Onset: h. Genitourinary Disease or Disorders: Urinary Incontinence Yes No Onset: Other Genitourinary Conditions Yes No Onset: i. Gynecological Disease or Disorders: Amenorrhea (absence of periods) Yes No Onset: Dysmenorrhea (painful/heavy periods) Yes No Onset: Infertility Yes No Onset: Other Gynecological Conditions Yes No Onset: j. Psychiatric/Psychological Disorders: Depression Yes No Onset: Bipolar Disorder Yes No Onset: 1/24/2014 6
7 Suicidal Thoughts Yes No Onset: Physical/Sexual Abuse Yes No Onset: Other Psychiatric/Psychological Conditions Yes No Onset: Family History: List all medical problems of family members, such as Heart Disease, Lung disease, Diabetes, Cancer or Obesity along with the relationship to the patient: Do you use tobacco products? Yes If yes, how much /day and type No Quit Do you drink alcohol? Yes If yes, how much/day or week No_ Quit Have you ever had a substance abuse problem? Yes If yes, specify No Quit COMPLICATIONS FROM ANESTHESIA: Have You or Anyone in Your Family had complications from anesthesia? Yes No If yes, please describe: BLEEDING TENDENCIES: Have you ever experienced any prolonged bleeding from dental or surgical procedures? Yes No If yes, please describe: Can you walk up a flight of stairs without stopping? Yes No How far can you walk without stopping? Can you put on/tie you shoes and socks? Yes No Can you perform adequate hygiene after a bowel movement? Yes No Can you perform necessary household chores/activities? Yes No Can you fit in a theater/airplane/amusement park seat? Yes No 1/24/2014 7
8 What can t you do because of your obesity? How do you think weight loss surgery will help you medically, psychologically or personally? 1/24/2014 8
9 Record in the space provided what you might typically eat including type and amount of food. Meal s Food Eaten and Amount Breakfast Snack Lunch Snack Dinner Snack 1/24/2014 9
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